Do you or a loved one have PTSD?

There is no need to suffer.

Treatment works.

If you have PTSD—posttraumatic stress disorder—you don’t have to suffer. There are good treatments that can help. This booklet describes therapies and medications that are proven to help people with PTSD. You’ll hear from experts about what treatment is like, and how it can help you.

Don’t let PTSD get in the way of your enjoyment of life, hurt your relationships, or cause problems for you at work or school.

PTSD treatment works.

This guide covers:

Treatment That Works ..........2

Myths About Treatment .....7

Success Stories ...................8

Resources ..............................8

Produced by the National Center for PTSD | February 2011 U.S. Department of Veterans Affairs | www.ptsd.va.gov

UnderstandingP T S D

Treatment

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T reatment That Works

What is PTSD?Posttraumatic stress disorder, or PTSD, can occur after someone goes through or sees a traumatic event like:

Combat exposure•

Child sexual or physical abuse•

Terrorist attack•

Sexual/physical assault•

Serious accident•

Natural disaster •

Most people have some stress-related reactions after a traumatic event. Fear, sadness, guilt, anger, and sleep problems are common. You may have bad memories of the event. If your reactions don’t go away over time and they disrupt your life, you may have PTSD.

Symptoms of PTSDPTSD has four types of symptoms:

Reliving the event (also called reexperiencing): •Memories of the trauma can come back at any time. You may have nightmares or feel like you are going through it again. This is called a flashback.

Avoiding situations that remind you of the event:• You may try to avoid situations or people that bring back memories of the event.

Feeling numb:• You may find it hard to express your feelings. It also may be hard to remember or talk about parts of the trauma.

Feeling keyed up (also called hyperarousal): • You may be jittery and on the lookout for danger. You might suddenly become angry or irritable. This is known as hyperarousal.

Available TreatmentsThere are good treatments available for PTSD. The two main types are psychotherapy, sometimes called “counseling,” and medication. Sometimes people combine psychotherapy and medication. The following treatments for PTSD work:

Cognitive Behavioral Therapy (CBT), such as•

Cognitive Processing Therapy (CPT)•

Prolonged Exposure Therapy (PE)•

Eye Movement Desensitization and Reprocessing •(EMDR)

Medications called Selective Serotonin Reuptake •Inhibitors (SSRIs)

Getting BetterCBT, EMDR, and SSRIs have the best evidence for treating PTSD. Researchers around the world have examined them. They have found better outcomes for people who get these treatments than for people who receive other treatments, or no treatment at all.

All three treatments can cause positive and meaningful changes in symptoms and quality of life for the people who use them. “Getting better” means different things for different people, and not everyone who gets one of these treatments will be “cured.” But they will likely do better than people with PTSD who were not treated, or who received other kinds of treatment.

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Psychotherapy (Counseling)Cognitive behavioral therapy (CBT) is the most effective treatment for PTSD. CBT usually involves meeting with your therapist once a week for up to four months. There are different types of cognitive behavioral therapy. The two most-researched types of CBT for PTSD are Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE).

Cognitive Processing Therapy (CPT)Why it works: Trauma often causes people to struggle with memories and thoughts of the event. You may get “stuck” on these thoughts and feel unable to make sense of the trauma.

CPT can give you skills to handle these distressing thoughts. It helps you understand what you went through and how the trauma changed the way you look at the world, yourself, and others. In CPT, you will focus on examining and challenging thoughts about the trauma. By changing your thoughts, you can change the way you feel.

CPT has four main parts:Learning about your PTSD symptoms and how •treatment can help

Becoming aware of your thoughts and feelings•

Learning skills to challenge your thoughts and •feelings (cognitive restructuring)

Understanding the common changes in beliefs that •occur after going through trauma

In addition to regular meetings with your therapist, you will get practice assignments to help you use your new skills outside of therapy.

What is Cognitive Processing Therapy?

Tara Galovski, PhD Psychologist and Assistant Professor

University of Missouri, St. Louis

“In CPT, we examine what you’re thinking and telling yourself about your trauma and decide whether those thoughts are accurate or inaccurate. For example, frequently people heap blame on themselves for these awful things that happened, saying things like, ‘It’s my fault that my buddy died,’ or ‘I shouldn’t have worn a short dress; that’s why I was raped.’

These inaccurate thoughts cause a lot of distress. So together we challenge those thoughts to see if we can come up with a conclusion that’s more accurate, more balanced.

In CPT, we’re not changing the details of what happened, we’re changing the things that you’re telling yourself that are increasing your PTSD symptoms. If you start telling your mind more accurate things, then all of a sudden the tunnel starts to open up a little bit. And once you’ve started thinking in this way, you don’t stop. Your mind opens up to different possibilities. The relief is just inevitable. It’s not a magic bullet. It’s just logic.

It never ceases to amaze me how people can change remarkably in a very brief time. When people come back for a three-month or a six-month follow-up visit, many times I have walked out into the waiting room and not even recognized the person! Hats are off, nail polish is on, weight lost, hair done up…It’s pretty remarkable.”

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Prolonged Exposure Therapy (PE)

Why it works: Repeated exposure to thoughts, feelings, and situations that you have been avoiding helps you learn that reminders of the trauma do not have to be avoided. In PE, you and your therapist will identify the situations you have been avoiding. You will repeatedly confront those situations until your distress decreases.

PE has four parts:

Education: to learn about your symptoms and how •treatment can help

Breathing retraining: to help you relax and manage •distress

Real world practice (• in vivo exposure): to reduce your distress in safe situations you have been avoiding

Talking through the trauma (imaginal exposure): •to get control of your thoughts and feelings about the trauma

PE usually involves 8–15 sessions with a therapist, plus practice assignments you will do on your own. With time and practice, you learn to manage your reactions to stressful memories.

What is Prolonged Exposure?

Matthew Yoder, PhD Psychologist

Department of Veterans Affairs

“PE is a treatment that helps people face their fears. Think of a wound on the battle field; a person’s out there fighting and they get a deep cut in their arm. They wrap it up with the bandage in their hip pocket and keep fighting. After the battle, they go back to the base and they have this wound. It’s a deep gaping wound with a field bandage on it. There’s a lot of dirt in there that can get infected.

The person has to decide what they want to do: do they want to take the bandage off and clean it out, or do they want to leave the bandage on and take their chances that it’ll heal on its own?

Most of the time, they need to take the bandage off and clean out the wound, and that’s what exposure therapy is. It’s facing something that can be a little painful and hurtful at the beginning, but it’s a treatment that helps the person do that at their own pace.”

Why is exposure important?

Kevin Beasley, LCSW Social Worker Department of Veterans Affairs

“One of the things that I tell patients is that treatment is going to involve not only talking about your trauma in a lot of detail, but taping that and listening to those tapes daily. And we’re also going to do what we call in vivo exposure.

What that means is going out into the environment to practice and relearn that under a different set of circumstances that bus stop where you were raped is just a bus stop. That trash on the side of the road---if you’re a Veteran and you had an IED blow up---well, in a different set of circumstances, that trash is just trash. We’re having you experience some of those things in this environment so that you can make the connection that there has been a change. And then your body actually starts to change its reaction. You won’t get as anxious.“

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Eye Movement Desensitization and Reprocessing (EMDR)Why it works: In EMDR, you focus on hand movements or tapping while you talk about the traumatic event. The idea is that the rapid eye movements make it easier for our brains to work through the traumatic memories. Focusing on hand movements or sounds while you talk about the traumatic event may help change how you react to memories of your trauma over time. You also learn skills to help you relax and handle emotional distress.

EMDR has four main parts:• Identification of a target memory, image, and belief

about the trauma

• Desensitization and reprocessing: focusing on mental images while doing eye movements that the therapist has taught you

• Installing positive thoughts and images, once the negative images are no longer distressing

• Body scan: focusing on tension or unusual sensations in the body, to identify additional issues you may need to address in later sessions

Over time, EMDR can change how your react to memories of your trauma. A course of four to twelve sessions is common.

What is EMDR?

Susan Rogers, PhD Psychologist

Department of Veterans Affairs

“When a client comes in for EMDR, I ask them to

identify the most disturbing part of the trauma

memory. Usually there is one image that is the

most disturbing. I ask them what negative belief

about themselves goes with that picture, what

emotion they’re feeling, what sensations they

feel in their body, and then have them focus on

that while we do brief sets of eye movements. I

usually just have them follow my hand back and

forth with their eyes.

The idea behind EMDR is that PTSD symptoms

are really a matter of incompletely processed

experience. Your brain is designed to take

everyday experiences, sort them out, store the

useful parts, and get rid of the part you don’t need.

When a trauma happens, some people get kind of

hung up and don’t complete the processing. They

need some assistance from therapy and that’s our

goal: to help somebody sort the memory out.

The eye movements help people relax enough

to think clearly about the trauma, sort it all out,

and resolve it.”

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MedicationSelective Serotonin Reuptake Inibitors (SSRIs)

Why they work: SSRIs can raise the level of serotonin in your brain, which can make you feel better. The two SSRIs that are currently approved by the FDA for the treatment of PTSD are sertraline (Zoloft) and paroxetine (Paxil).

Possible side effects that may occur in fewer than one out of three people who take SSRIs include:

• Nausea (feeling sick to your stomach)

• Decreased interest in sex

• Feeling drowsy, tired, or sleeping too much

PTSD medications may interact with other medications you are taking. You should check with your doctor about all medications you are taking.

Will I be on medication forever?

Matthew J. Friedman, MD, PhD Psychiatrist, VA National Center for PTSD

Professor, Dartmouth Medical School

“If a person has had a good response to

medication, the likelihood is that he or she is going

to need to be on that medication indefinitely. Now

what I do with my patients is, if they’ve had a good

year of symptom-free living, then we’ll test the

waters. I’ll reduce the dose gradually, and if we can

get away with it, I’m more than happy to stop the

medication. But more often than not, people need

to stay on their medication indefinitely.

That’s the big difference between therapy and

medication; with medication you need to be

on it indefinitely for the most part, whereas

for psychotherapy, you typically need 10–12

sessions and maybe a ‘booster’ now and then.

You don’t need much more. So for a patient that

doesn’t want to be on medication indefinitely,

that can be another motivation for them to go

into psychotherapy.”

Warning: Sometimes, doctors prescribe medicines called “benzodiazepines” for people with PTSD. These medicines are often given to people who have problems with anxiety. While they may be of some help at first, they do not treat the core PTSD symptoms. They also may lead to addiction, especially for people who have had problems with alcohol or drugs. So, benzodiazepines are not recommended for long-term PTSD treatment.

Questions to Ask a Potential Therapist

What is your education? Are you licensed? How many years have you been practicing?

What are your special areas of practice?

Have you ever worked with people who have been through trauma? Do you have any special training in PTSD treatment?

What kinds of PTSD treatments do you use? Have they been proven effective for dealing with my kind of problem or issue?

What are your fees? (Fees are usually based on a 45–50 minute session.) Do you have any discounted fees? How much therapy would you recommend?

What types of insurance do you accept? Do you file insurance claims? Do you contract with any managed care organizations? Do you accept Medicare or Medicaid?

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Your therapist should explain the therapy, how long treatment is expected to last, and how to tell if it is working.

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M yths About TreatmentMyth: Therapists just nod their heads and listen. Fact: CPT, PE, and EMDR are active treatments where

the patient and therapist work together. Therapists are very engaged. Sessions are goal-oriented. Elements of treatment are skills-based.

Myth: Therapy goes on for years and years. Fact: CPT, PE, and EMDR are all time-limited treatments

Myth: Therapists “get inside your head” to change who you are.

Fact: Therapists help you understand your thoughts and feelings so that you have more control over them.

Myth: I can get better on my own.Fact: If you have had PTSD for a year or more, the

chance of getting better without counseling or medication is quite small.

Myth: If I have to talk about trauma, I’ll “lose it.” Fact: Therapy takes place in a safe, controlled

environment, and you work with the therapist to go only as far as you feel safe. You learn coping skills to help you manage your anxiety.

Myth: Only a therapist who’s been through what I’ve been through understands this well enough to help me.

Fact: Providers with and without their own trauma histories can effectively deliver PTSD treatments. What’s important is that the provider has good training and experience, and can help you develop the skills you need to get better.

Myth: All I need to get better is the support of other people who’ve been through what I’ve been through.

Fact: Support groups can provide social support and interpersonal connection, but there’s little evidence that they help the PTSD symptoms themselves.

Myth: My trauma happened a long time ago, so treatment won’t work.

Candice Monson, PhD Psychologist and Associate Professor

Ryerson University

“No matter how long it’s been, there’s good reason to think that you can get better.”

“One thing that I’ve heard from older Veterans that

I’ve treated is, ‘I can’t believe how much time I’ve

wasted; that I’ve been living with these symptoms

for 35 years. Why didn’t I do this before?’

Thirty years ago, we didn’t know how to treat

PTSD. Just like other areas of medicine, we’ve

come a long way. So ask yourself, do you want

to spend the rest of your years living with your

symptoms? What might your life look like if you

were free of them? Even if you’re an older person

who’s had your symptoms for a long time, the

therapy still works, and there’s hope for you to

have a different life.

The most important thing is just to address it. No

matter how long it’s been, there’s good reason to

think that you can get better.”

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S uccess StoriesMaria used to enjoy socializing, but after she was mugged, she couldn’t even go on simple outings with her family. Driving was difficult. Going to a movie theater was impossible. When she did manage to go out to dinner, she was so focused on what was going on around her that she couldn’t enjoy her meal or join the conversation.

After treatment, things changed. Now, she can sit down with her family and enjoy a meal at a restaurant. She can even spend a day at an amusement park, where there are crowds

“I still have some things that bug everywhere, and not be anxious.

me,” she says, “but my life has improved so much that the things that bother me are just small.”

George is a Vietnam Veteran who’d been a medic. A Vietnamese mother brought her badly injured child to his field hospital. He was unable to save the child, who died in his arms.

Back home, he never held his own children. “I never held

my kids, never changed their diapers. I didn’t want to have that reminder.” But with the birth of his first grandchild he decided to get help. His therapy was a success. At the end of his treatment he showed his therapist a picture of himself with his grandson in his arms. He said, “I love holding my grandson. And you know what? I couldn’t hold my kids then, but I’m holding them now.”

R esourcesTrea ment ResourcestThese links are accessible online at www.ptsd.va.gov/public/where-to-get-help.asp

Finding and Choosing a Therapis• t

Help for Veterans with PTS• D

Mental Health Services Locato• r

Veterans Affairs PTSD Program Locato• r

Where to Get Help for PTS• D

More About PTSD TreatmentView the multimedia companion to this booklet and other resources at www.ptsd.va.gov/public/

This guide was created by the National Center for PTSD, U.S. Department of Veterans Affairs. The Center conducts research and education on trauma and PTSD. Our website offers extensive information, educational materials, and multimedia

presentations for a variety of audiences, including Veterans and their families, providers, and researchers. Website: www.ptsd.va.gov